INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25 - 26, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Abstinent Living At The Turning Point At Washington Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on May 27, 2011.
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Plan of Correction
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of personnel records and an interview with the Office Supervisor, the facility failed to document Federal (FBI) criminal background checks in three of three personnel records. The facility failed to document a Department of Public Welfare (DPW) Childline Clearance and Pennsylvania State Police Clearance in two of three personnel records.
The findings include:
Four personnel records were reviewed on April 25, 2011. Three new employee personnel records were reviewed for documentation of criminal background clearances required by the Child Protective Services Law (CPSL). The facility provides non-hospital inpatient residential treatment and rehabilitation services for women with children. The women and their children reside at the facility. Act 73 of the Child Protective Services Law, now requires that employees of addiction treatment facilities hired after July 1, 2008, that have "significant likelihood of regular contact with children in the form of care, guidance, supervision or training" obtain three background checks as a condition of employment. These background checks include: a Pennsylvania State Police Clearance, Department of Public Welfare (DPW) Childline Clearance, and a Federal (FBI) criminal background check including fingerprinting.
Employee # 2 was hired as the Facility Director on September 9, 2011. There was no documentation of a Federal (FBI) criminal background check in personnel record # 2, at the time of the review on April 25, 2011. Employee # 2 would have significant likelihood of regular contact with children.
Employee # 3 was hired a counselor on January 31, 2011. There was no documentation of a Federal (FBI) criminal background check, DPW Childline Clearance and Pennsylvania State Police Clearance in personnel record # 3, at the time of the review on April 25, 2011. Employee # 3 would have significant likelihood of regular contact with children.
Employee # 4 was hired as a Resident Monitor on September 21, 2010. There was no documentation of a Federal (FBI) criminal background check, DPW Childline Clearance and Pennsylvania State Police Clearance in personnel record # 4, at the time of the review on April 25, 2011. Employee # 4 would have significant likelihood of regular contact with children.
The Office Supervisor was interviewed throughout the licensing process and confirmed the criminal background clearances required by CPSL were not completed for any of the employees of the facility. On April 26, 2011, the Office Supervisor began the process of FBI criminal background checks and fingerprinting for all employees.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records and interview with the Office Supervisor, the facility failed to document long and short term goals for treatment as formulated by both staff and client in three of four client records.
The findings include:
Four client records were reviewed on April 26, 2011. Four client records required long and short term goals for treatment as formulated by both staff and client. The facility failed to document long term goals in client record # 4. The facility failed to document short term goals in client records # 1, 2 and 4.
Client # 1 was admitted into treatment on March 8, 2011. The individual treatment plan was completed on March 16, 2011. The treatment plan did not include documentation of short term goals, at the time of the review on April 26, 2011.
Client # 2 was admitted into treatment on March 1, 2011. The individual treatment plan was completed on March 2, 2011. The treatment plan did not include documentation of short term goals, at the time of the review on April 26, 2011.
Client # 4 was admitted into treatment on September 20, 2010 and discharged on March 18, 2011. The individual treatment plan was completed on October 8, 2010. The treatment plan did not include documentation of long and short term goals, at the time of the review on April 26, 2011.
The Office Supervisor was interviewed on April 26, 2011. The Office Supervisor confirmed client records # 1, 2 and 4 did not include short term goals and client record # 4 did not include long term goals.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(3) LICENSURE Records of Service
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Based on a review of client records and an interview with the Office Supervisor, the facility failed to document a record of services provided that included the duration of the service in two of four client records.
The findings include:
Four client records were reviewed on April 26, 2011. Four client records were required to include a record of services that included the duration of the service. The facility failed to document a record of services provided that included the duration of the service in client records # 1 and 2.
Client # 1 was admitted into treatment on March 8, 2011. The client has received weekly individual and group counseling sessions from March 8, 2011 to April 26, 2011. The record of services provided did not document the duration of the weekly individual and group counseling sessions.
Client # 2 was admitted into treatment on March 1, 2011. The client has received weekly individual and group counseling sessions from March 1, 2011 to April 26, 2011. The record of services provided did not document the duration of the weekly individual and group counseling sessions.
The Office Supervisor was interviewed on April 26, 2011 and confirmed the record of services provided in client records # 1 and 2 did not include the duration of the service. The Office Supervisor reported the record of services form had been revised and the duration of the service had inadvertently been removed from the form. The Office Supervisor corrected the form on April 26, 2011.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |